5.  1850 Semmelweiss found increased rate of mortality with puerperal sepsis patients and advocated hand washing to stop spread of disease  Died in a mental institution, work never recognized as important

6.  United States physicians insert > 5 million every year  Used for hemodynamic measurements, resuscitation, administration of medications and nutrition  15% of patients will have a complication

7.  Mechanical complications 5-19%  Thrombotic complications 2-26%  Infectious complications 5-26%  N Engl J Med 2003;348:1123-33

8.  In the U.S. 15 million CVC days  250,000 cases of CVC associated BSIs  Mortality 12-25%  Marginal cost is $25,000 per episode  Lowball $6.25 billion

9.  Average ICU rate of BSI 5.3/1000 catheter days  80,000 BSIs/ year in ICUs  Studies show no increase in severity adjusted mortality to 35% increase in mortality  ? Attributable mortality

10.  Cost per infection is $34,508-$56,000  Annual cost $296 million to $2.3 billion

11.  Data January 1992-June 2001  Group of nearly 300 hospitals  Med/surg rate major teaching 5.3%  Med/surg rate all others 3.8%  Rates influenced by severity, type of illness, elective or urgent placement and type of catheter

12.  Review current training for effectiveness, completeness  Define nurses’ role  Mechanism for monitoring compliance with training prior to ICU rotation  Establish strategy for identifying and training those we missed  Communication plan to housestaff and attendings  Implement training requirements

13.  Hand Hygiene  Maximal barrier precautions  Chlorhexidine skin antisepsis  Optimal site selection, subclavian vein preferred site  Daily review of need for line with prompt removal

14.  Assess allergies  Verify consent form completed and in chart  Assemble supplies with nursing staff  Time out-right patient, right location, assess site ◦ Review appropriate landmarks with attending ◦ Subclavian preferred site if not contraindicated

15.  Remember to employ maximal barrier precautions  Put on hat/mask for everyone in room  Minimize number of people in room  Close door prior to start of procedure  Wash hands  Sterile gown/gloves  Chlorhexidine prep of site ◦ Pinch wings of applicator to break ampoule ◦ Hold applicator down to saturate pad ◦ With sponge against skin, apply chlorhexidine for at least 30 seconds using a back and forth scrub ◦ Allow chlorhexidine to dry completely before beginning line placement (~2 minutes)

16.  Full body drape  Perform procedure  Transduce with pressure tubing to verify venous placement  Apply needleless caps, flush ports with saline  Suture catheter in place  Apply Biopatch  Apply Tegaderm  Appropriate disposal of kit/drapes  Order and check CXR for line placement  Procedure note in chart  Daily review of necessity of central line-advocate removal ASAP

17.  Development of Nursing checklist  Nursing Ed for skills day/orientation  CPC committee  Update intranet with this information  Utilize ICU nursing administration to keep at the forefront of many QI projects

18.  Inform patient/family of pending procedure  Assess allergies in chart  Verify informed consent present  Gather sterile supplies for maximum barrier precautions i.e. gowns, gloves, drapes, masks, hats  Needleless caps  Saline flush with syringes  Biopatch  Tegaderm

19.  Minimize number of people in room  Close door prior to start of procedure  Everyone in room with hat/mask  Everyone in room wash hands  Time out  Maximum barrier precautions  Monitor sterile process and alert for breaks in procedure  Clean site then apply Biopatch shiny or blue side up  Sterile occlusive dressing application  Obtain CXR for line placement  Inform family of outcome of procedure

20.  Review need for line on daily basis  Advocate removal/PIC  Monitor site q shift for signs/symptoms of infection, irritation, redress if needed  Alcohol ports prior to every access  Tubing/needleless port change q 4 days and more often as needed